A closer look at the WSJ's newest Obamacare horror story

By By Michael Hiltzik

Nov 06, 2013 | 6:05 AM

Is Edie Sundby's dilemma his fault? Read on. (Saul Loeb/AFP Getty)

The most prominent example of Obamacare victimization being offered at the moment comes from Edie Littlefield Sundby of San Diego, a businesswoman who related in a Wall Street Journal op-ed earlier this week how Obamacare is threatening her life by depriving her of access to her cancer doctors.

"I am a determined fighter and extremely lucky," she wrote, explaining that she has survived stage-4 gallbladder cancer for seven years through treatment by doctors at Stanford, UC San Diego and Houston's M.D. Anderson Cancer Center. "But this luck may have just run out: My affordable, lifesaving medical insurance policy has been canceled effective Dec. 31."

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The insurance policy in question has been provided up to now by United Healthcare, which Sundby praised as "fair," "responsive," and "caring." (That last term refers to "the people in the claims office.") The alternatives for 2014 Sundby has found via the California health exchange don't include all her current doctors in their networks, she reported. Because of the Affordable Care Act, she said, "I have been forced to give up a world-class health plan. The exchange would force me to give up a world-class physician."

There's no reason to doubt Sundby's dilemma in trying to continue her current treatment, or her conviction that her survival is the product of her particular lineup of doctors and hospitals. (Though her earlier interviews certainly suggest that her spirit, her tenacity, and the support of her husband may have had a lot to do with her survival.)

But what Sundby, 62, addresses in her op-ed is the question of whether Obamacare places her health at risk. There the evidence doesn't look so clear. In fact, there are signs that the Affordable Care Act might help save her.

It's plain from reading the many interviews Sundby has given over the last few years about her illness and treatment that she's a remarkable person. After she received her diagnosis in 2007, she took her treatment in hand, searching out doctors she thought right for her, fully participating in her therapeutic choices, and keeping physically and mentally fit. Any doctor would be lucky to have patients like her. Her survival for seven years is as close to a miracle as medical science can boast. She deserves our empathy.

Yet her op-ed doesn't provide all the information one would need to fully appraise her insurance situation. She doesn't divulge her premium for the UnitedHealth plan which is being withdrawn--she just says it's "affordable"--or its deductibles or out-of-pocket maximums, or whether her doctors are all within its approved network or out. She doesn't say whether UniHealth has raised her premiums since she first got the policy in 2005, or if it has, by how much. She doesn't reveal her income, though it's reasonable to assume that it might be too high to make her eligible for premium subsidies.

It's unclear whether her current insurance is a catastrophic coverage policy, as she's called it sometimes, or a standard PPO. She did say in an earlier interview that she and her husband have paid tens of thousands of dollars from their own pockets for her treatment, and in her op-ed she says UnitedHealth has forked over $1.2 million. Nor is it clear from the text that she would be paying higher premiums next year than she does now. (Her article seems to say only that she's found health plans outside the exchange that are costlier than plans offered by the exchange, but not how they compare with her current premiums.)

All that is the minimum one needs to know to understand the difference between what she's had up to now and what she can get for 2014 and beyond. I called Sundby to try to fill in these blanks, but she hasn't gotten back to me. If she does, I'll let you know.

But here's what we do know today.

UnitedHealth alerted Sundby way back in January that it was pulling out of the California individual insurance market entirely. An inescapable question is whether it did so because of Obamacare, or whether it's just using Obamacare as an excuse to do something it was itching to do anyway. UnitedHealth's own statements point to the latter.

The firm informed investors of its decision in May, when it announced it would exit the individual market in all but a dozen states. Since Obamacare's coverage standards are the same in all states, plainly it wasn't Obamacare—or Obamacare alone--that prompted its departure from California.

The more likely explanation is that UnitedHealth simply couldn't compete in California's individual market and no longer wished to try. As Igor Volsky of Think Progress and others have pointed out, the company served fewer than 8,000 individual customers in the state, where its chief focus is on the large-employer market. A company spokeswoman told MarketWatch that it had been struggling to deal with this tiny slice of business for quite some time: "Over the years, it has become more difficult to administer these plans in a cost-effective way for our members," she said. (Emphasis ours.)

The company also told investors that it was wary of the individual insurance exchanges in general because it figured that the wave of new enrollees in the first year or so would be the sickest and therefore most expensive. Apparently it's willing to face that risk in only a dozen states. Its message isn't an uplifting one: The company is cutting back on individual coverage because it doesn't want to serve high-cost patients—patients like, for example, Edie Littlefield Sundby.

What this tells you is that Sundby was fated to lose her UnitedHealth plan sooner or later, Obamacare or not. California law allows insurers to leave its customers high and dry if they choose to abandon an entire market. Sundby's insurer wanted out, and skipped town as soon as it could find a plausible excuse.

Its behavior is, indeed, a flaw of the Affordable Care Act, just not the one the Wall Street Journal wants you to think about. The flaw is that the act leaves the insurance system in the hands of profit-seeking firms like UnitedHealth, which don't want to serve customers most in need because they're not where the biggest profits are. The solution, naturally, is for government to cut commercial insurers out of the system entirely, but one suspects that's not what the editors of the Journal would favor.

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It's important to understand what Sundby's options would be in a non-Obamacare world, once UniHealth abandoned her: They'd be dire. As a stage-4 cancer patient, she'd be uninsurable except at an enormous price, and possibly not at all. (As far as UnitedHealth is concerned, she's already uninsurable.) The only reason she can find any replacement insurance policies to choose from today is that the Affordable Care Act now forbids carriers to reject her, to refuse to cover her cancer treatment, or to base her premiums on her medical condition.

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It's not a rap on Sundby to point out, moreover, that she's not representative of the typical individual insurance customer affected by the Affordable Care Act. (She and her husband are software entrepreneurs.)

A profile of health exchange enrollees prepared by the Kaiser Family Foundation in 2011 projected that more than 80% would be low-income Americans eligible for premium subsidies. They'd include 3.5 million people who had lost their employer-based insurance, 1.5 million whose shares of their employer-based insurance premiums exceeded the maximum percentage of their income allowed under Obamacare, and 2 million adults with incomes too high to qualify for Medicaid. An estimated 65% would be currently uninsured. Over one-third would be people who had gone more than two years without a check-up, and 29% would have had "no interaction with the health care delivery system" at all during the previous year. All these people will be better off under Obamacare.

As for Sundby, the idea that in the pre-Obamacare era, once UnitedHealth bailed out on her—as it surely intended to do eventually—she'd be able to find any insurer willing to cover her cancer treatment without restrictions, allow her to choose her own doctors and therapies without limit, and cap her personal financial exposure at any but a stratospheric level is, to put it bluntly, ludicrous. She may or may not know that, but the editors of the Wall Street Journal certainly do, and for them to put her story out as if her insurance problems would disappear if only the Affordable Care Act ceased to exist is nothing short of malpractice.